Provider Demographics
NPI:1730478827
Name:GUARDIAN PHARMACY OF EASTERN NC, LLC
Entity Type:Organization
Organization Name:GUARDIAN PHARMACY OF EASTERN NC, LLC
Other - Org Name:SOUTHERN PHARMACY SERVICES WINSTON-SALEM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:TERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:866-768-8479
Mailing Address - Street 1:GUARDIAN PHARMACY OF EASTERN NC DEPT 2416
Mailing Address - Street 2:P.O. BOX 11407
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35246-0001
Mailing Address - Country:US
Mailing Address - Phone:404-389-1383
Mailing Address - Fax:404-389-1384
Practice Address - Street 1:1031 E MOUNTAIN ST BLDG 319
Practice Address - Street 2:
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284-7998
Practice Address - Country:US
Practice Address - Phone:866-768-8479
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-30
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
NC109653336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
2130222OtherPK
2130222OtherPK